Embodied and narrative understandings of the self in schizophrenia: Advances from the study of metacognition and implications for psychotherapy Paul H.

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Presentation on theme: "Embodied and narrative understandings of the self in schizophrenia: Advances from the study of metacognition and implications for psychotherapy Paul H."— Presentation transcript:

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Embodied and narrative understandings of the self in schizophrenia: Advances from the study of metacognition and implications for psychotherapy Paul H Lysaker Roudebush VA Medical Center And the Indiana University School of Medicine

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Outline A space for the intersubjective in biological and social models of mental illness A space for the intersubjective in biological and social models of mental illness Metacognition and intersubjectivity Metacognition and intersubjectivity Quantitative methods for more assessing synthetic forms metacognition within personal narratives Quantitative methods for more assessing synthetic forms metacognition within personal narratives Example of empirical findings to date Example of empirical findings to date Application to psychotherapy Application to psychotherapy Conclusions Conclusions

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The same problem framed in service provision No home No Self- esteem Provide access to work No job Provide access to housing Provide access to self esteem No friends Provide access to friends

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The same problem framed in service provision access to work No job No friends access to friends

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Outline A space for the intersubjective in biological and social models of mental illness A space for the intersubjective in biological and social models of mental illness Metacognition and intersubjectivity Metacognition and intersubjectivity Quantitative methods for more assessing synthetic forms metacognition within personal narratives Quantitative methods for more assessing synthetic forms metacognition within personal narratives Example of empirical findings to date Example of empirical findings to date Application to psychotherapy Application to psychotherapy Conclusions Conclusions

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Aspects of self experience relevant to intersubjectivity Without a valuation of life and experience of persons with any condition, we hazard undermining the study of that disorder as a meaningful element of the human condition, amputating the person from the disorder Lysaker & Lysaker (2008). Schizophrenia and the Fate of the Self. Oxford University Press

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Aspects of self experience relevant to intersubjectivity Successful intersubjective activity carried out by embodied selves should have predictable traces, residues or metaphorical metabolites: A complex personal narrative in which self and others are portrayed in integrated and agentic manner That is: Synthetic metacognitive activity

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Metacognitive activities Discrete activities including noticing one is making an error or forming a belief about a specific belief – Roots in the educational literature Discrete activities including noticing one is making an error or forming a belief about a specific belief – Roots in the educational literature Synthetic activities including forming a coherent and complex ideas about oneself and others and thinking about that – Roots in attachment and related clinical literatures Synthetic activities including forming a coherent and complex ideas about oneself and others and thinking about that – Roots in attachment and related clinical literatures

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Level of metacognitive complexity Metacognitive activitiesCore processes assessedMemory processes employed Examples Highly discrete processes Noticing specific behaviors.Making accurate vs. inaccurate attributions. Declarative and working memory Noticing having made an error. Noticing one is performing poorly on a task Realizing one is the source of an action or thought. Moderately discrete processes Thinking specific things about a relatively circumspect aspects of one’s experiences. Endorsing vs. rejecting specific beliefs or label for a specific belief or emotion. Declarative memoryHaving a specific belief about a symptom or forming a belief about something one feels. Moderately synthetic processes Forming coherent and integrated ideas about of oneself and others. Representation of oneself and others which are more vs. less complex. Autobiographical and declarative memory Understanding how different thoughts and feelings affect each for oneself or another person. Highly synthetic processes Utilizing integrated ideas about oneself and others to solve psychological problems. Utilizing more vs. less complex representations of the self and others to respond to psychological problems. Autobiographical and declarative memory Using an awareness of how one differs from another person in terms of thoughts and emotions to repair an interpersonal conflict.

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Synthetic metacognitive activities Forming and reflecting about complex representations of oneself Forming and reflecting about complex representations of oneself Forming and reflecting about complex representations of other people Forming and reflecting about complex representations of other people Situating representations of self and others in the larger world with no singular center Situating representations of self and others in the larger world with no singular center The use of complex representations of self and others to solve emergent psychological challenges The use of complex representations of self and others to solve emergent psychological challenges

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Processes called for when assessing synthetic metacognitive activities Stimuli which are Stimuli which are Affect laden Affect laden Personally relevant Personally relevant Tied to episodic and implicit memory Tied to episodic and implicit memory Activities can occur spontaneously without repeated cues signaling the participant to form ideas of themselves and others Activities can occur spontaneously without repeated cues signaling the participant to form ideas of themselves and others

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Outline A space for the intersubjective in biological and social models of mental illness A space for the intersubjective in biological and social models of mental illness Metacognition and intersubjectivity Metacognition and intersubjectivity Quantitative methods for more assessing synthetic forms metacognition within personal narratives Quantitative methods for more assessing synthetic forms metacognition within personal narratives Example of empirical findings to date Example of empirical findings to date Application to psychotherapy Application to psychotherapy Conclusions Conclusions

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The Indiana Psychiatric Illness Interview Interview consists of 6 sets of prompts which are offered as the interview progresses Interview consists of 6 sets of prompts which are offered as the interview progresses Tell me the story of your life. Tell me the story of your life. Do you think you have a mental illness? Do you think you have a mental illness? Because of this what has and has not changed? Because of this what has and has not changed? What do you control/what controls you? What do you control/what controls you? How does it affect others/how do others affect it? How does it affect others/how do others affect it? What do you see in the future? What do you see in the future?

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The Indiana Psychiatric Illness Interview The goal is a spontaneous speech sample that The goal is a spontaneous speech sample that Provides a glimpse about how life and the experience of illness are narratized. Provides a glimpse about how life and the experience of illness are narratized. Provides an opportunity for synthetic metacognitive activity which can be rated. Provides an opportunity for synthetic metacognitive activity which can be rated. Is not largely scaffolded by the interviewer. Is not largely scaffolded by the interviewer.

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Assessing metacognition with IPII narratives The MAS-A consider metacognition as a series of semi-independent capacities. The MAS-A consider metacognition as a series of semi-independent capacities. Some capacities may be more impaired or more functional than others Some capacities may be more impaired or more functional than others These capacities involve increasingly complex tasks which are largely hierarchical in nature These capacities involve increasingly complex tasks which are largely hierarchical in nature The MAS-A Scales are in likert format and higher ratings are suggestive of greater metacognitive function The MAS-A Scales are in likert format and higher ratings are suggestive of greater metacognitive function

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MAS subscales Self reflectivity – representations of oneself Self reflectivity – representations of oneself Understanding the mind of the other – representations of other people Understanding the mind of the other – representations of other people Decentration – situating oneself and others in the world Decentration – situating oneself and others in the world Mastery – Using knowledge of mental states to solve psychological problems Mastery – Using knowledge of mental states to solve psychological problems

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9 Anchor points for self reflectivity 1. I know there are thoughts in my head 1. I know there are thoughts in my head 2. I know the thoughts are my own 2. I know the thoughts are my own 3. I can distinguish different cognitive operations 3. I can distinguish different cognitive operations 4. I can distinguish feelings 4. I can distinguish feelings 5. My conclusions are subjective 5. My conclusions are subjective 6. My wishes are not the same as reality 6. My wishes are not the same as reality 7. My thoughts and feelings are connected in the moment 7. My thoughts and feelings are connected in the moment 8. My thoughts and feelings are connected in consistent ways across many moments 8. My thoughts and feelings are connected in consistent ways across many moments 9. My thoughts and feelings are connected in across the larger story of my life. 9. My thoughts and feelings are connected in across the larger story of my life.

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9 Anchor points for mastery 1. No plausible problems. 1. No plausible problems. 2. Psychological problems but they are not plausible 2. Psychological problems but they are not plausible 3. Plausible psychological problem which is responded to passively by altering an internal state (e.g. eating or sleeping) 3. Plausible psychological problem which is responded to passively by altering an internal state (e.g. eating or sleeping) 4. Plausible psychological problem responded to by avoiding the issue or seeking support 4. Plausible psychological problem responded to by avoiding the issue or seeking support 5. Plausible psychological problem responded to behaviorally. 5. Plausible psychological problem responded to behaviorally. 6. Plausible psychological problem responded to cognitively. 6. Plausible psychological problem responded to cognitively. 7. Plausible psychological problem responded to by modifying beliefs on the basis of understanding the relationship between cognitions, emotions, behaviors, and relationships. 7. Plausible psychological problem responded to by modifying beliefs on the basis of understanding the relationship between cognitions, emotions, behaviors, and relationships. 8. Plausible psychological problem responded to as per level 7 but also an understanding of the relationship between cognitions, emotions, and behaviors in other people. 8. Plausible psychological problem responded to as per level 7 but also an understanding of the relationship between cognitions, emotions, and behaviors in other people. 9. Plausible psychological problem responded to as per above but understanding that not all cannot be completely controlled. 9. Plausible psychological problem responded to as per above but understanding that not all cannot be completely controlled.

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Outline A space for the intersubjective in biological and social models of mental illness A space for the intersubjective in biological and social models of mental illness Metacognition and intersubjectivity Metacognition and intersubjectivity Quantitative methods for more assessing synthetic forms metacognition within personal narratives Quantitative methods for more assessing synthetic forms metacognition within personal narratives Example of empirical findings to date Example of empirical findings to date Application to psychotherapy Application to psychotherapy Conclusions Conclusions

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Self reflectivity predicting work function over the next 6 months 56 males with schizophrenia or schizoaffective disorder 56 males with schizophrenia or schizoaffective disorder Modal age: Late 40s; Modal education: 12 years Modal age: Late 40s; Modal education: 12 years In outpatient treatment at a VA Medical Center or community mental health center In outpatient treatment at a VA Medical Center or community mental health center Often with a history of multiple hospitalizations Often with a history of multiple hospitalizations Prescribed anti-psychotic medication Prescribed anti-psychotic medication Completed 4 of a 6 month vocational placements Completed 4 of a 6 month vocational placements Lysaker PH, Dimaggio G, Carcione A, et al., (2010). Metacognition and Schizophrenia: The capacity for self- reflectivity as a predictor for prospective assessments of work performance over six months. Schizophrenia Research. 122(1-3), 124-130

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Effects of neurocognition upon social function are mediated by metacognition: Path analysis N = 102 with schizophrenia or schizoaffective disorder N = 102 with schizophrenia or schizoaffective disorder Male and female; Age: Late 40s ; Modal education: 12 yrs Male and female; Age: Late 40s ; Modal education: 12 yrs In outpatient treatment at a VA Medical Center or community mental health center In outpatient treatment at a VA Medical Center or community mental health center Often with a history of multiple hospitalizations Often with a history of multiple hospitalizations Prescribed anti-psychotic medication Prescribed anti-psychotic medication No hospitalizations within the last month No hospitalizations within the last month Lysaker PH, Shea AM, Buck KD, et al., (2010) Metacognition as a mediator of the effects of impairments in neurocognition on social function in schizophrenia spectrum disorders. Acta Psychiatrica Scandinavica 122(5), 405-413.

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Other Findings After controlling for neurocognition and symptoms Mastery is linked to After controlling for neurocognition and symptoms Mastery is linked to A biases to jump to conclusions in probabilistic reasoning task A biases to jump to conclusions in probabilistic reasoning task Performance on the planning comprehension subscale of the UPSA Performance on the planning comprehension subscale of the UPSA Buck KD, Warman DM, Huddy V & Lysaker PH (In press). The relationship of metacognition with jumping to conclusions among persons with schizophrenia spectrum disorders. Psychopathology Lysaker PH, McCormick BP, Snethen G, Buck KD, Hamm JA, Grant MLA, Nicolò G & Dimaggio G. (In press). Metacognition and social function in schizophrenia: Associations of mastery with functional skills competence. Schizophr Res

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Other Findings MAS-A and ToM capacities have a unique links with different domains of insight MAS-A and ToM capacities have a unique links with different domains of insight Self-reflectivity is most closely linked to awareness of symptoms Self-reflectivity is most closely linked to awareness of symptoms Awareness of the other was correlated to awareness of treatment needs Awareness of the other was correlated to awareness of treatment needs Mastery and the Hinting Test were correlated to awareness of consequence of illness Mastery and the Hinting Test were correlated to awareness of consequence of illness Lysaker PH, Dimaggio G, Buck KD, Callaway SS, Salvatore G, Carcione A, Nicolò G & Stanghellini G. (2011). Poor insight in schizophrenia. Comprehensive Psychiatry.52(3) 253-260.

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Ongoing studies MAS-A predicts function in a Turkish sample with symptoms remission (poster presented) MAS-A predicts function in a Turkish sample with symptoms remission (poster presented) MAS-A and PANSS ratings in an Italian schizophrenia sample (submitted) MAS-A and PANSS ratings in an Italian schizophrenia sample (submitted) MAS-A and attachment in a Scottish first episode sample (data collected) MAS-A and attachment in a Scottish first episode sample (data collected) MAS-A and depression in a Danish sample (data collected) MAS-A and depression in a Danish sample (data collected) MAS-A and first episode psychosis sample in a French Canadian sample (data collected) MAS-A and first episode psychosis sample in a French Canadian sample (data collected) MAS-A and first episode psychosis sample in an Israeli sample (data collected) MAS-A and first episode psychosis sample in an Israeli sample (data collected) MAS-A in combat PTSD and their partners (data collection) MAS-A in combat PTSD and their partners (data collection) MAS-A in homeless sample (data collection) MAS-A in homeless sample (data collection)

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Outline A space for the intersubjective in biological and social models of mental illness A space for the intersubjective in biological and social models of mental illness Metacognition and intersubjectivity Metacognition and intersubjectivity Quantitative methods for more assessing synthetic forms metacognition within personal narratives Quantitative methods for more assessing synthetic forms metacognition within personal narratives Example of empirical findings to date Example of empirical findings to date Application to psychotherapy Application to psychotherapy Conclusions Conclusions

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Psychotherapy could be a place to develop various capacities for metacognition: Psychotherapy could be a place to develop various capacities for metacognition: *Self reflectivity *Mastery*Decentration Interventions could be keyed to help persons to practice metacognitive acts consonant with their current abilities Interventions could be keyed to help persons to practice metacognitive acts consonant with their current abilities MAS could assess change over time MAS could assess change over time

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Targeting a capacity – not content or solving an issue or problem Targeting a capacity – not content or solving an issue or problem Helping people practice and learn to perform a particular cognitive act Helping people practice and learn to perform a particular cognitive act Seeing improvements as occurring along on a continuum – not as categorical Seeing improvements as occurring along on a continuum – not as categorical

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Case 1: Greig 1 Divorced man in his 50s Divorced man in his 50s High school education High school education Lived in his community Lived in his community Outpatient psychiatric care for undifferentiated schizophrenia. Outpatient psychiatric care for undifferentiated schizophrenia. Hallucinations, delusions thought disorder since his early 20s Hallucinations, delusions thought disorder since his early 20s No periods of symptom remission. No periods of symptom remission. Blunted affect and lack of volition Blunted affect and lack of volition Disorganized speech and significant levels of anxiety. Disorganized speech and significant levels of anxiety. Multiple hospitalizations, lost jobs, social alienation, Multiple hospitalizations, lost jobs, social alienation, No substance abuse or legal problems. No substance abuse or legal problems. Grave impairments in memory and executive function Grave impairments in memory and executive function 1 All identifying information in this report has been systematically disguised

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Sketch of Greig’s progress over 2.5 years Exploration/confrontation of delusions Exploration/confrontation of delusions Discussion of conflicting feelings about adult children Discussion of conflicting feelings about adult children Processing losses inherent in divorces Processing losses inherent in divorces Focus on inability to love Focus on inability to love Discussion of sense of “self-as-loser” Discussion of sense of “self-as-loser” Detailing his symptoms of mental illness Detailing his symptoms of mental illness

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Case 1: Greig Two transcripts per month selected Two transcripts per month selected MAS blindly rated for MAS for the first 32 weeks MAS blindly rated for MAS for the first 32 weeks MAS rated for exploratory purposes for the following 2 years MAS rated for exploratory purposes for the following 2 years Correlation of MAS with time is 0.70; p
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Case 2: Scarlatti 1 Divorced man in his 40s Divorced man in his 40s College education College education Lived in his community Lived in his community Received outpatient psychiatric care for paranoid schizophrenia. Received outpatient psychiatric care for paranoid schizophrenia. Hallucinations and delusions since his early 20s Hallucinations and delusions since his early 20s No periods of symptom remission. No periods of symptom remission. Denial of illness Denial of illness Pressured speech and significant levels of anxiety. Pressured speech and significant levels of anxiety. Multiple hospitalizations, lost jobs, social alienation, substance abuse and legal problems. Multiple hospitalizations, lost jobs, social alienation, substance abuse and legal problems. Grave impairments in memory Grave impairments in memory 1 All identifying information is systematically disguised

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Outline A space for the person in biological and social models of mental illness A space for the person in biological and social models of mental illness Metacognition and its relevancy for recovery Metacognition and its relevancy for recovery Quantitative methods for metacognition within personal narratives Quantitative methods for metacognition within personal narratives Example of empirical findings to date Example of empirical findings to date Application to psychotherapy Application to psychotherapy Conclusions Conclusions

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Conclusions The study of schizophrenia is not complete without the consideration of the person The study of schizophrenia is not complete without the consideration of the person How persons thinking about their thinking mediates the impact of schizophrenia. How persons thinking about their thinking mediates the impact of schizophrenia. Synthetic metacognitive activities may be assessed quantitatively. Synthetic metacognitive activities may be assessed quantitatively. Metacognition may be a foci of psychotherapy. Metacognition may be a foci of psychotherapy.

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Limitations One form of assessment of metacognition One form of assessment of metacognition Studies were conducted in one lab Studies were conducted in one lab Participants were generally in their 40s in a later stage of illness Participants were generally in their 40s in a later stage of illness Replication is needed with more diverse samples Replication is needed with more diverse samples Longitudinal studies are warranted Longitudinal studies are warranted